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0 0 <br /> From. 6616349233 Page: 314 Date: 224/2009 8.54:19 AM <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT <br /> ,,TYPE <br /> ��BELOW- <br /> TANK RETROFIT ❑ PIPING REPAIR/RETROFIT 11 UDC REPAIRlRETROFIT US..COLD START/EVR UPGRADE <br /> FA EPA Site# Project Contact 8 Telephone# 7' V,s �p,,,.,,S y 3 y^`✓Ki <br /> C Facility Name 4 Pf I Phone# <br /> 9 <br /> L Address Z- <br /> I <br /> T Cross Street 1. <br /> Y Owner/Operator rL Phone# <br /> C Contractor Name I 66 ,Gin(^qq f-o <br /> /� ,� G Phone <br /> T Contractor Address .V,dux 0 a >C� 3 " CA Lic# q oI(h 3 Class /� <br /> A Insurer S� Work Comp# $L{Q <br /> OICC Technician's Name' (jty5mrA .y.S Expiration Date & <br /> R ICC Installer's Name �/rxv) S ar Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (I.o.9i pbinB pump,91 Wk tlrl[tlae,UDD 1a,k0.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> PApproved <br /> L Approved with conditions ❑ Disapproved <br /> A (see merit With Conditions) <br /> N Plan Reviewers Name Dai <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE r-011oWINQ •I CERTIFY THAT IN <br /> THIS PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TOWORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING 9CERTIFY <br /> THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS sUBJECTTC WORKER'S COMPENSATION LAWS <br /> OF CAL FORNIA,- <br /> Applicant's Slpnatum Tltla Oaie <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. H <br /> the party designated below Is different than the permit applicant, e.g. Property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME_ 1)9JkC Clr4s.4i <br /> , fs, . 1 nTL�E Crc-'110'k�k /4s' -f- PHONE# 7-1'dS3 �S <br /> ADDRESS 0 .4 <br /> 9S-ZG(- <br /> SIGNATUR � DATE Z/-Y'A`� <br /> EH230OW(revised 02120109) <br /> i <br /> This fax was received by GFI FAXmaker fax server.For more information,visit http:l www.gft.com <br />